Medicare Part D or Prescription Drug Coverage.

Anyone who has Medicare Part A or Medicare Part B coverage is eligible for Part D of Medicare coverage. Part D is used to subsidize the costs of prescription drugs for Medicare beneficiaries. Part D was enacted as part of the 2003 Medicare Modernization act and went into effect on January 1, 2006. Medicare beneficiaries can obtain Part D through two types of private plans: a Prescription Drug Plan (PDP) or a Medicare Advantage Plan (Part C) that covers both medical services and contains a prescription drug plan. Approximately two-thirds of Part D beneficiaries are enrolled in the PDP option.

Eligibility

Those who are entitled to benefits under Medicare Part A and/or are enrolled in part B are eligible for Part D. Beneficiaries are able to obtain the Part D coverage through two types of private plans, more than two-thirds of Medicare recipients are enrolled in the first type of drug coverage.

Enrollment in a Prescription Drug Plan (PDP) for drug coverage only
Enrollment in Part C – Medicare Advantage – which covers both medical costs and drug coverage as well.
Generally, not all prescription drugs are covered at the same level – this is designed to give beneficiaries an incentive to choose certain drugs over others – for example generic over brand name. This is implemented through a system of tiered formulas where lower costs drugs are assigned to lower tiers, making them easier to prescribe and at a lower cost.

Duel Eligibility: Some Medicare beneficiaries are deemed to be dual-eligible. This means that they qualify for both Medicare and Medicaid. In this case, the beneficiary has an income which falls below their states qualification guidelines for Medicaid. In January of 2006, those with duel eligibility (receiving both Medicare and Medicaid drug benefits) were transferred from Medicaid to Medicare Part D – through an auto enrollment with one of the least expensive PDPs in their area – which was chosen at random.

Enrollment

Most Medicare beneficiaries must affirmatively enroll in Part D Drug Coverage in order to participate. The current enrollment period runs from October 15th to December 7th , beneficiaries who are eligible for Part D, but do not enroll during the enrollment period, but choose to do so at a later time will pay a late-enrollment penalty in order to receive Part D benefits. You can find a PDP by using the Medicare Plan Finder.

Coverage

Each Medicare Prescription Drug Plan has its unique list of covered medications – this is referred to as a ‘formulary’. The medications that the plans cover are placed into tiers within the formulary and the medications placed within the tiers are given a different cost. Medications in lower tiers will cost less than medications in the upper tiers.

If your doctor prescribes you a medication which is on an upper tier and your physician feels that no similar drug on a lower tier is right for you, you or your prescriber can request an exemption which will give you a lower co-pay for that medication. To find out which plans cover your medications, use the Medicare Plan Finder.

With the exception of vaccines which are covered under Medicare Part B, all Medicare Drug Plans must cover all commercially available vaccines, such as the shingles vaccine, when they are medically necessary to prevent illnesses and disease.

Auto-Refill: In the past some Part D beneficiaries used an auto-refill plan, the plan would automatically refill prescriptions, and send them to the beneficiary in the mail. However, some PDP’s weren’t making sure that the beneficiary still needed the medication and pharmacies cannot restock prescription drugs if they are sent through the mail. Some auto delivery services were creating a significant amount of waste and unnecessary costs for the Medicare Part D Program. To resolve this issue, effective January 2014, PDP’s will require your approval, prior to shipping refills – unless you request the refill yourself first. If you are already on an auto delivery program for your Part D prescriptions, be sure to let your PDP provider know the best way to reach you. This new policy will not affect those who physically pick up their prescriptions, nor will it apply to long-term care pharmacies.